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Perspectives on AIDS - Between fear, ignorance and disbelief in
Haiti - Which responses in the Caribbean?
March 1999
by: Ronald Colbert, Independent Journalist
The people of Haiti are waiting for the outcomes of a national
policy to combat Acquired Immuno-Deficiency Syndrom (AIDS), a disease
which continues to gain terrain. As yet, in the country, no multi-disciplinary
nor multi-sectoral mechanism has assumed real leadership on the
AIDS issue. Not only there are technical responsibilities to be
fulfilled, but also institutional and structural ones, on the levels
of government, society, private sector as well as financing agencies.
In September 1998, an update was published concerning the epidemiological
projections of HIV and AIDS in Haiti. In this paper, a group of
specialists stated that presently there are 335,000 cases of HIV
infection in the country, about 8.35% of the economically active
population.
This figure confirms observations for the Caribbean, made by the
Caribbean Epidemiology Centre (CAREC), based in Trinidad, which
show that persons in the 15-45 age bracket - considered as the most
productive in a given country - form the population category that
continues to be most likely to catch the AIDS virus. Beyond erosion
of public funds, the high price to be paid includes a less effective
work force and serious implications for the future development of
a country, according to specialists.
In this context, Caribbean countries could see an annual loss of
US$1.5 billion over the next ten years "because more persons
in the productive age bracket (economically active) catch the disease",
according to a recent projection made by CAREC and the Economics
Unit on Health of the University of the West Indies, reported on
29 January 1999 by Inter-Press Service.
This study by CAREC highlights that 2% of the Caribbean inhabitants
between 15-50 years of age are infected by the AIDS virus. Therefore,
the Caribbean region is second in the world beyond Sub-Saharan Africa
with an increasing HIV infection rate. Amongst the English-speaking
countries of the region, in 1996, the Bahamas show the highest incidence
rate, 134.3 per 100,000 inhabitants.
A Washington Post article published in 1998 revealed that the treatment
costs of AIDS, estimated at 3 billion dollars yearly in the Caribbean,
have put a strain on the already limited resources of many countries,
"particularly in the case of Haiti, the poorest nation of the
Western hemisphere and at the same time the island with the highest
HIV rate in the region".
Only by mid-December 1998, political decision makers gathered,
during a workshop organized by the Haitian Medical Association and
the Gheskio Centres, to establish a budgeted operational plan for
the upcoming two years. At the time of writing this briefing, no
information has filtered through relating to the decisions taken
during this workshop regarding the allocation of resources.
"Action against AIDS must be a concerted one. Until now, a
multidisciplinary approach which mobilizes all the actors involved
in combating AIDS has not been developed. In addition to lack of
resources, the national strategic plan which was launched in 1996,
faces an absence of follow up and of the systematic convening of
training sessions" acknowledges Dr. Joelle Deas Van Onacker,
Head of the Department of Sexually Transmitted Diseases (STD-AIDS)
at the Ministry of Public Health and Population (MSPP).
The MSPP official couldn't give information on the amount set aside
by the government to combat the epidemic. However, she announced
that, in collaboration with partner organizations, a manual is being
finalized on managing therapeutic and psycho-social aspects of infected
persons "which should assist all the country's health institutions
in taking into account opportunistic infections". She added
that "intervening on the STDs equals intervening on the incidence
of AIDS".
"Although many interventions have been made to prevent the
incidence of AIDS in other countries, in our country we lack any
vigorous action in this sense", deplored Dr. Eddy Génécé
of Promoters of the Goal Zero-AIDS (POZ). He attributed this lack
of action to a number of political and economical factors.
Dr. Génécé poses that in Haiti, the absence
of real commitment and collaboration between the various institutional
players strengthens the skepticism of the people concerning the
magnitude of AIDS. "Not only are the symptoms of the disease
invisible, its incidence appears stationary since 1990, in spite
of the projections of September 1998 which should alarm anybody",
he states.
In Jamaica, $2.4 million is devoted every year to the treatment
of infected persons, $1.4 million of which pertains to hospital
care, IPS reported in citing the Jamaican Minister of Health John
Junor. In 1999, 17 years after the first case of AIDS was detected
in this country, the rapid spread of the disease has begun to seriously
erode the scarce resources of the administration.
Continuous raising of public awareness
Many groups give the impression that attention to the AIDS issue
is restricted to the occasion of World AIDS Day, each year on December
1st.
"AIDS should be a daily subject for raising awareness, because
the disease strikes all the time and everywhere", stated Augustin
Bernard, one of the facilitators in a programme targeting youth
at the Foundation for Reproductive Health and Family Education (FOSREF).
FOSREF provides information on preventing STD-AIDS in various parts
of Port-au-Prince and several provincial cities.
J., a young Haitian lady who lost her husband to AIDS, stated that
efforts to build awareness on the disease won't have any impact
when only done occasionally. According to her, the biggest effort
and commitment should be provided by the government, which is the
principal responsible entity for organizing society and for putting
infrastructure in place to benefit the marginalized people. Action
should also be taken at the level of medical personnel, nurses and
hospital aides in order to emphasize the prevalence of other diseases
that are as serious as AIDS.
"The way that the health system is organized doesn't show
that infected persons are being taken into consideration. This is
very difficult. It is very rare to find a nurse who is really committed
to help infected persons. Moreover, they usually are exhausted because
of their providing care for a high number of patients. They don't
find enough time to help and listen to them. You become like a thing
... ', she added.
Protection and solidarity with infected persons
In light of the fear and disarray arisen by AIDS, Dr. Génécé
of POZ suggested that a law should come out to guarantee jobs for
infected people and to protect their individual and collective rights,
in spite of their being seropositive.
"Institutions have their roles. But, as in other countries,
we must strive, through national participation, to define a policy
that encourages infected persons to benefit from means of support",
acknowledged Dr. Génécé. He has stimulated
the accessibility of care through pilot-projects and encouraged
research on types of treatment that Haitian pharmacologists could
administer to ease the pain of patients.
Cuba experienced an outbreak of new cases of persons infected with
HIV in 1997. The Cuban government authorized that year a public
information campaign worth $ 600,000 and permitted social workers
to support prostitutes and homosexuals directly, according to a
Washington Post report of 1998. Cuba "which undertakes since
many years one of the most controversial programmes on the HIV virus,
requiring persons tested seropositive to live in government Sidatoriums",
now has the lowest prevalence rate (0.02%) amongst all the Caribbean
countries.
The Caribbean Epidemiology Centre (CAREC), based in Trinidad, works
with its country members (which include practically all the English-speaking
Caribbean countries) to improve the quality of virus detection tests
and to establish accrediting systems for laboratories and workers,
the Washington Post reported. In addition to helping countries to
find funds for programmes to combat AIDS, CAREC has been involved
also in researching manners of sexual behaviour and has carried
out, in schools and through the mass media, education campaigns
aimed at promoting more careful sexual behaviour.
According to the Health Minister John Junor, as cited by IPS, at
present the government of Jamaica is intensifying efforts to "educate
the public on the disease in an attempt to encourage Jamaicans to
practice healthy life styles".
In Haiti, efforts are being carried out by the private sector and
non-governmental organizations, who complain about the absence of
any concrete commitment by the public sector. However, the unit
in charge of STD-AIDS at MSPP has just announced that the Ministry
will soon open 5 detection centres, which together with 5 already
existing ones, aim to ensure the availability of screening services
country wide.
Several Haitian specialists have called at many occasions to cease
practices of discrimination and exclusion, which makes infected
persons confine themselves in silence. Since 1990, only a few people
have clearly declared their seropositive status. In spite of showing
solidarity, the circle of family and friends around an infected
person usually is not willing to talk about it, for fear of the
gossip that may result.
"We must not forget that AIDS has known moments of turmoil,
just like this country. However during 1998, we have done our utmost
to implement a continuous programme, through rural festivals in
the Departments of the North, Grand Anse, the South (festival of
Gelée) and the South-East (national youth campaign in August
in Jacmel). Certainly, the creation of awareness on AIDS is costly
and we couldn't get all that we wished. However, we try to do the
maximum", argues Dr. Van Onacker.
Furthermore, the Medical Association of Haiti (AMH), through the
media, pointed out the need to establish an ethics commission to
administer the vaccine which will be tested in March 1999 on voluntary
seropositive persons in the country. Such a commission should include
lawyers as well as human rights defenders, according to a researcher
of AMH. Nobody knows till now which institution will be responsible
to test the vaccine on the seropositives. In addition to AMH members,
no other official voice has said a word on the vaccine to be tested,
according to the international press.
A campaign centered on youth
Like many countries in the world, on 1 December 1998, the unit
in charge of STD-AIDS at MSPP closed the "Ronaldo" public
campaign (named after the 21-year old Brazilian soccer player),
which invited everyone to protect oneself in a responsible manner
against the effects of the AIDS-virus. This national campaign, that
addressed youth - one of the most vulnerable groups, which will
define tomorrow's profile of the epidemic - has benefitted among
others from the support of Volunteers for the Development of Haiti,
with whom MSPP convened information and cultural animation sessions
in various parts of Haiti.
Insisting on the complexity of the problem, Dr. Génécé
revealed that the rate of youth attendance at health centres is
very low. Those aged 15 and 16 don't visit hospital centres nor
clinics because they rarely feel flu and fever symptoms. Besides,
the concept of youth clinics was only recently introduced.
The representative of POZ pledged for the implementation of intensive
information campaigns at all levels (schools, media, public markets,
community development institutions). At the academic level, the
Ministry of Education should consider inserting the concept "sexuality"
into curricula as well as convening relevant training programmes
for teachers. The issue of tourism is also very important and condoms
should be made available in hotel rooms, as a prevention mechanism.
In order to encourage more responsible social behaviour among youth,
FOSREF regularly holds series of training sessions on different
themes, including STD-AIDS. Youngsters are invited to participate
for free in dance clubs, in language or handicraft courses, as well
as in the information network organized by the foundation. As a
way of prevention, a course "sex and gender" was to be
introduced in December 1998, to encourage youth to reflect on the
concept "machismo" which they tend to include in their
daily behaviour, and in particular in their sexual relationships.
High-risk groups and transmission mechanisms
Many admit that machismo, culturally strong in the country and
encouraging the seeking of multiple partners, remains a principal
cause of infection with AIDS.
Under the pretext of virility, a number of men do not consent to
use a condom. And when they submit themselves to this precaution,
they abandon the condom rapidly when the relation becomes steady
or "serious" (one or two months after the first intercourse),
states a specialized magazine from Martinique. Several women in
Haiti, especially under the majority class, also say that they do
not support condoms. Giving up of the use of condoms very often
occurs without any information or knowledge on the partner's serologic
status.
Specialists signal that the risks of transmission to other people
increases significantly during the first months of infection, since
the first signs of the disease will only appear after a relatively
long period.
Besides cases of teenagers who ignore the risks, researchers find
that the most likely people to contract or spread AIDS are those
who move around frequently. These include male or female prostitutes,
policemen and security agents, militaries, truck and bus drivers,
rural migrants, as well as people going back and forth between the
Dominican Republic and Haiti.
"The great mobility of certain social strata, who get into
situations prone to new sexual liaisons, increases the risk of infection.
These persons have no knowledge of the health status of their occasional
partners. As such, transmission can take place. In this context,
an interminable time can pass before the first symptoms of the disease
become apparent", explained Dr. Génécé.
The representative of POZ recalls the two important stages of AIDS:
there are infected persons who ignore it because of not having any
symptoms; and here are also those with deficiency symptoms who are
forced to stay in bed.
Transmission of the AIDS virus takes place primarily through sexual
intercourse, according to a number of specialists who argue that
today the transmission by contaminated blood material is under control.
According to a Washington Post article, in 1998, 65% of reported
cases in the Caribbean had resulted from heterosexual transmission.
The same sources confirmed that 35% of all the HIV infected adults
in the Caribbean are women and the prevalence rate amongst pregnant
women is increasing every year.
At the beginning of 1999, Dr Beatrice Hahn (Alabama University/USA)
with the support of a team of American researchers, located the
origin of HIV 1, the most dangerous one of the two AIDS viruses,
to the chimpanzee. This animal would be a natural reservoir and
could pass the virus on to humans.
In addition to their historical interest, the discoveries of Dr.
Hahn launches hope to develop a vaccine that could help humanity
to protect itself, through understanding how the monkeys, bearers
of the virus, do not become sick themselves. Since the genes of
humans and chimpanzees are for 98% alike, "it's likely that
these monkeys live with a virus control mechanism", Dr Hahn
emphasized.
Besides the number of 300,000 deaths in Haiti due to AIDS, the
September study revealed an increase in transmission from mother
to children. The number of orphans due to AIDS would be about 190,000
in 1998 in Haiti.
Because of extreme poverty, many women cannot negotiate their sexual
power and find themselves economically dependent on the male partners.
Sometimes in addition to having a first partner, they enter into
relationships with others, ignoring their serological status and
their sexual past.
Reports about the evolution of the disease in the Caribbean cite
inadequate health care, lack of education or information on AIDS,
constant use of illegal drugs, and the sex industry as factors that
contribute to increase the cases of HIV infection.
In Haiti, amongst other causes of the spreading of AIDS, are economic
regression, poverty, serious sexual promiscuity, "monogamy
in series", drugs and homosexuality.
POZ noticed that the question of homosexuality has not been dealt
with in any part of the national strategic plan to combat AIDS "because
this is a taboo subject". A current study by POZ reveals the
existence of serious problems around the homosexual community, which
includes all the social strata: poor, middle class and bourgeoisie/elite.
According to Dr. Génécé: "This is a specific
problem that is different from other pathologies. Homosexuals must
use lubricant condoms because of their undertaking anal relations.
The quality of lubricant is an important factor. All lubricants
which are not based on water will cause the condom to tear. Sometimes,
the homosexuals use butter or vaseline in place of condoms. "Who
ensures the availability of lubricating condoms in the country?",
wonders the representative of POZ.
In the Caribbean, as opposed to the situation in other parts of
the world, the correlation between HIV and intravenal drug use is
extremely low, except in Bermuda where more than 40% of reported
cases result from drug injection, states the Washington Post.
The environment in question
The September 1998 study, done by Haitian specialists, underlined
that there is a considerable impact of HIV infection on the incidence
and prevalence of tuberculosis, a disease that can be caught in
Haiti through ordinary contact. This threatens to notably disrupt
the programmes to combat tuberculosis, for the number of tuberculosis
cases due to AIDS is five times higher than the number of tuberculosis
cases expected. In 1998, this number was between 45,000 and 60,000
against 11,000 expected cases.
"The risk of infection of the general population, which was
already high in Haiti before the AIDS epidemic appeared, has become
worse. Close to 50% of the adults and 18% of the children hospitalized
with T.B in Port-au-Prince are seropositive. Tuberculosis reaches
40 to 50% of the persons currently living with HIV and it is actually
the first cause of death. Equally, AIDS is complicating the treatment
of tuberculosis and thus can raise cases with resistance",
underlines the study.
In Carrefour Feuilles, a suburb in the south-east of the Haitian
Capital, the Association for the Promotion of Family Integral Health
(APROSIFA) carries out a programme called "Take a Chance"
(UCAP). It targets a serious environmental situation with a population
in danger of being a gateway to HIV infection.
"The filthy and unhealthy environment and lack of ventilation
in certain areas of this suburb increases the risk of spreading
T.B among the inhabitants, some of whom show symptoms of respiratory
illnesses. Exposed to microbes, the inhabitants are also faced with
promiscuity, lack of toilets and latrines, and have difficulty finding
food and potable water. The doubtful quality of available water
promotes the development of STDs in the cervical smear. All the
health counsels and all medical and psycho-social training confront
the same dilemma: the socio-economical conditions of life in the
slums", notes Ilionor Louis, who is in charge of the Psychological
Training Service at UCAP.
APROSIFA`s programme runs an out-patient clinic in Carrefour Feuilles,
receiving 200 patients monthly. Cases of recurrence are rare except
for HIV. Every morning, about 60 people, men and women, participate
in information, education and communication (IEC) sessions on the
mechanisms of transmitting STD-AIDS.
In addition to a good thirty animators constantly in the field
(at churches, schools, cock fighting) to stimulate responsible behaviour
against STD-AIDS, the programme has launched a strategy of occupational
therapy for a group of seropositive persons who are willing to share
their experiences.
The type of exchanges and activities to be accomplished by seropositive
people together, has not been defined as yet. But, it includes the
planning of meetings between two or more HIV infected people, under
the supervision of a psychologist or social worker. In this way,
voluntary mutual aid groups are organized, which may pay visits
to other sick persons.
Perspectives for action against AIDS
Several officials interviewed for this paper, suggested the establishment
of a permanent structure with an appropriate budget and public health
agents throughout the entire country who can contribute to the prevention
of STD-AIDS. In addition, screening should be instituted in health
centers.
"Nothing will be accomplished when we stay in the current
situation. Let's hope that with the ratification of a prime minister
the soonest, there will be an appropriate structure. A programme
to combat AIDS needs to be verticalised at the national level, through
a structure capable to ensure leadership, as well as horizontalised
at the province level. Haiti may not have sufficient resources at
its disposal for an intensive awareness campaign, but funds can
be mobilized by various agencies and collected from the private
sector, which is willing to contribute. It will no longer be necessary
for the health agents to intervene in education which already has
a specific budget for specific activities", indicates Dr. Génécé.
Ilionor Louis of UCAP proposes the creation of a "Sidatorium",
"not to put HIV infected persons in quarantine as in the sanatorium
in Carrefour Feuilles for T.B patients, but to have a centre equipped
with all what is needed for a normal life: play grounds, spaces
for creativity and integration".
Is there hope for a decrease in the infection rate? Dr. Joelle
Deas Van Onacker of the unit in charge of STD-AIDS at MSPP admitted
that this is difficult to answer. "We are only at the beginning
of involving the various actors in the fight for decreasing the
prevalence of AIDS in Haiti".
Dr James Hospedales, director of CAREC wished in a report to IPS
that:"We must simply stop the trends of this disease, because
if we don't, projections indicate levels of incidence which are
extremely serious for the development of our countries".
Notes.- The majority of data in this briefing result from interviews
and information collected in November 1998. An update was prepared
in February 1999.
(1) The figures, available at the Haitian Institute of Statistics
and Information (IHSI) and dated 1995, state that 4,010,814 inhabitants
form the economically active population (age brackets 15 to 64)
for the entire country. Based on projections awaited for 1998, the
percentage of infected persons as part of the economically active
could be lower. (2) A set of statistical information on the Caribbean
countries, except for Haiti, was provided by CAREC until 1996. There
is also a document entitled "Impact du SIDA" which follows
the epidemiological projections in Haiti, prepared by the Policy
Project.
References
CAREC (Caribbean Epidemiology Centre)
16-18 Jamaica Boulevard
Federation Park
Republic of Trinidad and Tobago
Tel : (868) 622-4261
Fax (868) 622-2792
E-mail : carec@wow.net
Unité MST-SIDA du MSPP-Haiti
rue Saint-Honoré
Port-au-Prince (ancien local Hôpital militaire)
POZ (Promoteurs Objectif Zéro SIDA)
2 rue Tertulien Guilbaud
Bourdon, BP 1261
Port-au-Prince, Haiti
Tel/Fax : (509) 245-4396 / (509) 245-5330
E-mail : poz@acn2.net
FOSREF (Fondation pour la Santé Reproductrice et l'Education
Familiale)
41 angle Avenue John Brown et Rue Jardines
Port-au-Prince
Tel : (509) 223-7375 / (509) 223-7377
UCAP-Extension (Une Chance A Prendre, un programme de l'Association
pour la Santé Intégrale de la Famille - APROSIFA)
122 Route des Dalles
Port-au-Prince
Tel : (509) 221-3420
AMH (Association Médicale Haitienne)
24 rue Capois
Port-au-Prince
Tel : (509) 222-8233/223-9394
Fax : (509) 223-9885
Email : amh@haitiworld.com
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